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22 Health systems in transition France Delivery of care is shared among private, independent physicians, public hospitals, private non-profit-making hospitals and private profit-making hospitals. Alongside the health care sector and the social sector, there is a combined health and social care sector, the “third sector”, that provides care and supportive services to elderly and disabled people. 2.2 Historical background The present system of social security, including SHI, was established after the Second World War. Prior to this, health and social care were largely provided through mutual benefit associations. The statutory system first emerged with the 1930 Act on Social Insurance, which created a system of compulsory protection paid for by employers for employees whose earnings fell below a certain level. Coverage encompassed five areas: illness, maternity, disability, old age and death. By 1939, two-thirds of the French population was covered for illness by mutual benefit associations, with free choice of the organization providing coverage. The creation of SHI in 1945 within the social security system changed the role of these associations, which either disappeared or became providers of VHI (see section 3.3.2). Social security consists of compulsory protection, with four branches covering health, work-related illness and injuries, retirement and family. SHI is the branch of social security covering health (disease, maternity, incapacity and death) and is funded by contributions from both employers and employees, with benefits provided in cash and in-kind. While the founders of the social security system, largely inspired by the Beveridge report in the United Kingdom, aimed to ensure uniform rights for all, this was opposed by certain social–professional groups that already benefited from insurance coverage with more favourable terms. Several of them succeeded in maintaining their particular systems, which were transformed into small SHI schemes. However, today, three main SHI schemes cover 95% of the population (see section 2.3.5). Initially, SHI covered workers and their families only. However, the principle of expanding coverage to the whole population had been raised as early as 1945 but was only put into practice in stages (for more details, see section 2.2 in Chevreul et al., 2010). The shift from an employment-based system towards the CMU system was nearly achieved with the 1999 Universal Health Coverage Act (Loi No. 99–641 du 27 juillet 1999 portant création d’une couverture maladie universelle), which
Health systems in transition France 23 instituted a residency-based right to SHI coverage and created the CMU Fund (Fonds CMU; see section 3.2) to provide free public coverage for individuals whose incomes fall below a certain level; individuals above this threshold who are not entitled to SHI on an occupation basis must pay a share of their income to be covered on a voluntary basis by SHI. Undocumented immigrants are not eligible for access through CMU. However, those who have lived in France for at least three months are eligible for free coverage under the state medical assistance (aide médicale de l’état; AME) (see section 3.3.1). In parallel, from the late 1990s, funding methods on the beneficiary side have shifted from an earned income-based social contribution to an earmarked tax, the CSG (see section 3.3.1). 2.3 Organization The current institutional organization of the health system is the result of the will of the founders of the social security system to create a single block system, guaranteeing uniform rights for all. Health insurance in France, therefore, has always been more concentrated and uniform than in other Bismarckian systems. Another key difference is that the French SHI has never really had the management responsibilities accorded to SHI regimes and funds such as those in the German health care system. The state rapidly took responsibility for the financial and operational management of SHI (e.g. setting premium levels and the prices of goods and services), and nowadays management responsibilities are shared between the state and SHI. 2.3.1 The parliament The parliament has control over the health care system and its resources. It has control over health policy priorities by passing public health acts. The first Public Health Act was passed in 2004 (Loi No. 2004–806 du 9 août 2004 relative à la politique de santé publique) and a new one is expected in late 2015. The parliament has control over resources by passing an annual Social Security Finance Act. This Act is proposed by the government, based on the reports of (1) the Auditor’s Office (Cours des comptes), which is an independent public body responsible for monitoring state and social security bodies, to ensure adequate control over and proper use of public funds; (2) the High Council for the Future of Health Insurance (Haut conseil pour l’avenir de l’assurance maladie; HCAAM); (3) the High Council for Public Health (Haut conseil de
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7. Assessment of the health system
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